Diagnosis:
High risk for falls related
to confusion as
evidenced by
disorientation to place,
time, situation, unsteady
gait, generalized
weakness
Subjective Data:
Patient asking, “who are
you again?”
Multiple family stated,
“he doesn’t seem right”
Patient stated, “I feel
weak when I get up”
Objective Data:
History of dementia
Set off bed alarm
continually during night
Requires walker for
ambulation
Patient will wear non-
skid socks when out of
bed: to provide stability
during ambulation
Patient’s bed alarm will
be on at all times: to
alert staff if patient is
attempting to get out of
bed independently
Patient will be relocated
to a room closer to the
RN station: to enable
staff to visualize patient
on a more frequent
basis
Nurse will increase
frequency of rounding:
to assess needs more
frequently, toilet more
often, reorient.
Patient utilized non-skid socks
during all periods of
ambulation, did need to be
continually reminded, as he
does not like socks, per his
report. Will continue to
promote.
Patient’s bed alarm was on
consistently throughout shift
and patient did set alarm off
approximately 4-6 times. Will
continue to have bed alarm
on.
Another confused patient
occupied the room closest to
RN station; will move if room
becomes available.
Patient rounded on q 30 min
or q 1 hour. Noted that
patient became agitated
when he had to use the
bathroom during first
rounding, therefore offered
toileting with each visit and
noted decrease in agitation.
Will continue to round
frequently.
Patient remained injury and
fall free during this shift. Goals
progressing.
